The American Psychiatric Association Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians1 is a welcome resource document for forensic examiners who perform independent medical examinations of potentially impaired physicians. Anecdotal and published reports indicate that requests for such evaluations are growing2; hence, there is growing attention to the process of conducting these examinations and of highlighting important pitfalls and clinical concerns in evaluating fellow physicians.

While there has always been a need for guidelines for fitness-for-duty evaluations of physicians, there have been emerging trends in who orders such evaluations of physicians and why. With the change from a fee-for-service system to a managed-care environment as well as the increasing complexity of the provision of health care, fewer physicians are their own bosses and increasingly must be able to participate cooperatively within a health care team. These changes can be in conflict with traditional expectations held by some physicians about the authority and autonomy of the profession. Physicians can be stressed by such changes, and that stress can sometimes translate into disruptive behavior.3 In addition to patients’ making complaints, paraprofessional employees (such as nurses and aides) may feel more empowered to make complaints about a physician’s behavior. Most hospitals have now created policies pertaining to disruptive behavior of physicians based on American Medical Association guidelines4 and Joint Commission on Accreditation of Health Care Organizations standards,5 which can prompt request for a fitness-for-duty evaluation of a physician.

While hospitals and physician health committees of medical associations can request fitness-for-duty evaluations, complaints about the behavior of physicians and requests for such evaluations are now more frequently the province of state medical boards. Because state medical boards can revoke the license of the physician being examined, and because hospitals can revoke privileges, the results of the fitness-for-duty evaluation can have powerful financial and therapeutic impacts on the physician who has come to the attention of his or her employer or state medical board. The forensic psychiatric assessment can also have major implications for the examinee when the findings have the potential for public access, as described in the resource document.

These days, medical associations typically have roles that are more therapeutic than sanctioning. In the past, however, this was not always the case. For example, it was not uncommon for the American Psychiatric Association’s district branch, state association, or national ethics committees to have a role in evaluating the conduct of psychiatrists. These assessments were internal, and so the reporting of the findings was sometimes less formal. However, with its increased focus on advocacy for patients and other broader agendas over the past few years, the Association has less time and fewer resources to pursue internal investigations of physicians. Further, the outcome of investigations by specialty societies have not always had the good impact desired by the physician community. Adverse findings have sometimes resulted in little more than the termination of membership in the specialty association, while allowing the evaluee to continue practicing medicine. Although the American Psychiatric Association’s procedures for handling complaints of unethical behavior now includes an educational option for less serious violations, instead of relying solely on an enforcement option,6 again, complaints about physician behavior and requests for such evaluations are now more frequently the province of state medical boards.

Conducting the Evaluation

The resource document discusses traditional reasons for referral, such as psychiatric disorders including substance abuse, and cognitive impairment. It discusses the need for behavior assessment to determine whether the behavior is attributable to mental illness, to maladaptive personality traits, or to unethical or illegal acts such as threatening behavior or sexual misconduct. The document also describes the need to define clearly the role of the examiner and the reason for the consultation.

While the resource document provides general information on conducting the fitness-for-duty evaluation, other documents contain more specific recommendations for conducting the face-to-face interview.7,8 Although it may not be clinically required, it is often helpful from a clinical perspective to have the evaluee sign a consent form authorizing the release of the report to the requesting source in advance of the interview. Such a practice can help underscore the importance of the evaluation to the evaluee, who may have minimized its need, and can lead to a deeper discussion about the limits of confidentiality at the outset of the evaluation. Mandating the release of information in advance can also lead to the evaluee’s discussing the evaluation more fully with an attorney. Although this is largely helpful, there is a risk that doing so may result in the evaluee’s being less forthcoming during the interview.

If the physician has a history of mental illness, it is important to consider compliance with medication as a factor in the current situation. Psychological testing may be of additional benefit in evaluating relevant personality issues. In addition to recommendations contained in the resource document, it may be important to discuss the evaluee’s personality characteristics, coping strategies, tolerance of frustration, and whether there have been similar instances of problematic behavior and, if so, how those instances relate to the current situation. When relevant, understanding the culture of the health care organization with which the physician is affiliated is helpful in conducting the clinical assessment as well.

Implications of Clinical Recommendations

Impaired physicians sometimes have little insight into their behavior or need for change and/or treatment, and they may persist in their belief that their behavior is not a problem. Providing detailed reasoning to support the findings in the fitness-for-duty report may be a tool in helping the evaluee come to terms with his or her impairment.

If the physician’s license is suspended or revoked, the fitness-for-duty evaluation can become the first step toward a coordinated effort to treat and monitor an impaired physician. These evaluations can often translate into mandated, confidential treatment, which frequently has state medical association oversight.8

Describing the reason for the decompensation or disruption in behavior and the signs and symptoms of illness and noting whether the physician has the capacity to work collaboratively with the health care environment become all the more important when recommendations are used to guide treatment. If impairment is present, the evaluee’s clinical needs should be identified, and recommendations should include interventions necessary for the physician to return to work. Since treatment recommendations can sometimes help define how recovery will be gauged, the advice should be specific enough to help the referral source understand exactly how the physician will be found fit for duty in the future. It may also be helpful to define the behavioral expectations of the physician when he or she returns to work, which can include delineating reasonable and competent behavior. As such, recommendations may also include education in interpersonal skills or other efforts toward rehabilitation, particularly when there is a need to minimize or eliminate disruptive conduct.3

Credibility of the Process

Ultimately, the outcomes and recommendations of these evaluations can be serious, life-changing, and/or career-changing events for physicians receiving them. While the fitness-for-duty evaluation is often a first step toward managing impaired physicians, it is important to remember that the major focus of the assessment and intervention to assist a potentially impaired physician is not the care of the physician, but the protection of the public.8 Politicians, the public, and even members of the state board may perceive that the physician evaluator has favorable bias toward the evaluee because of the perception that guild members protect their own.7 Providing a rational description of and justification for a declaration of impairment can help strengthen the credibility of physicians who assess their peers. A high-quality fitness-for-duty evaluation is the best defense against accusations of bias. Good reports, aided by good guidelines such as the APA’s resource document, help make medicine accountable for itself and strengthen the trust needed among organized medicine, our professional colleagues, governing agencies, and patients.